Provider Demographics
NPI:1295140036
Name:SAM'S HPUSE
Entity type:Organization
Organization Name:SAM'S HPUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDER-GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1262-527-1282
Mailing Address - Street 1:PO BOX 13201
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-0201
Mailing Address - Country:US
Mailing Address - Phone:262-262-5271
Mailing Address - Fax:
Practice Address - Street 1:505 N 26TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2528
Practice Address - Country:US
Practice Address - Phone:262-262-5271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health